I'm hoping you can help me guide my dad in choosing a treatment approach for his newly diagnosed prostate cancer.

My dad is 69. He has type II diabetes for about 6 years now that was until recently managed with diet and exercise. He has mild high blood pressure. Otherwise, he's a healthy guy who is quite fit. I should add that he's a pretty anxious guy.

His PSA had been bouncing around for the last 6+ months, including a high of just above 8. He had abx after that and it came down to the 4-6 range. Nothing felt on DRE. His dr. did a biopsy that came back positive.

From the pathology report, it looks like they took more than 12 cores, though I'm not sure how many - I am guessing 16. Everything on the left side was okay and most of the cores on the right hand side were not. 6 of 8 were positive on the right side with between 15 and 35% of the core involved. All the Gleasons are 3+3. No evidence of perineural or lymphovascular invasion. So, T2b. He had follow up bone scan, CT scan, and lung xray, which were clear.

I went with him to the doctor to get results of the bone scan, etc. That was all fine so then the doctor started discussing treatment options. He mentioned active surveillance but discussed it only very briefly. He then moved to surgery or radiation. He is recommending radiation (45 days) accompanied by androgen suppressors for several months. The way he was describing the surgery vs. radiation option, the chances of side effects are similar with each (he said he could try nerve sparing surgery on the left hand side but not on the right) and it seems he thinks radiation will do a better job of getting any lingering cells that may have made it slightly beyond the prostate. I am pretty clear on where on the severity scale my dad's cancer is, but I am having trouble figuring out if radiation is the way to go here or whether surgery is better - i'm thinking of this from a "cure" perspective, a side effect perspective, and a peace of mind perspective for my dad. He's had friends go through this and they've all had surgery, so I think the recommendation for radiation has thrown him for a bit of a loop. Any thoughts?

Hi,
Sorry to hear about your father's diagnosis. One comment of the diagnosis, you said:

Quote:

So, T2b.

but you also said:

Quote:

Nothing felt on DRE.

If nothing was felt on the DRE and no further imaging was done, he is stage T1c. The stage is not based on the pre-treatment biopsy, if that was a supposition on your part. The reason this is important is that stage T1c together with PSA under 10 and Gleason 6 squarely puts him in the low risk category. This makes sense, since his doctor recommended Active Surveillance.

PC like your father's is typically slow growing, so he has lots of time to explore options, including getting on an AS program.

In addition to AS, he may be a candidate for hemi-ablation -- getting rid of the right side of the gland only.

In terms of permanent cure rates for low risk disease, all of the following, if done at centers of excellence, are in the 95% cure range (as measured by freedom from biochemical (PSA) failure after 5 years): surgery (robotic, laparoscopic or open), HDR brachytherapy monotherapy, CyberKnife, and LDR brachytherapy (seeds). IGRT/IMRT and standard proton therapy are almost as good. Pencil beam proton (available at MD Anderson and UF Jacksonville) is very promising after a couple of years.

As your father learned from his friends, surgery is certainly the most popular option with about 70% of newly diagnosed men electing to have it. Surgery is also the most problematic in terms of side effects: incontinence, impotence, etc. "Nerve sparing" reflects a wish on the surgeon's part -- small nerves have to be severed -- sometimes they grow back, sometimes they don't.

The kinds of radiation therapy I mentioned as being the most curative (CyberKnife and brachys) also have the least side effects. There is no reason to have hormone therapy along with any of them, especially for low risk disease.

Urologists are usually ill-informed about the various radiation therapies, their cure rates and side effects. Unfortunately, you will have to talk to radiation oncologists in each of those specialties to gain a proper prospective. I went through five urologists and radiation oncologists before deciding. Fortunately, your father has the time to do so.

- Allen

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